Tangcharoensathien, V; Witthayapipopsakul, W; Panichkriangkrai,W; Patcharanarumol, W; Mills, A (2018) Health systems develop-ment in Thailand: a solid platform for successful implementation ofuniversal health coverage. Lancet. ISSN 0140-6736 DOI: https://doi.org/10.1016/S0140-6736(18)30198-3Downloaded from: http://researchonline.lshtm.ac.uk/4646912/DOI: 10.1016/S0140-6736(18)30198-3Usage GuidelinesPlease refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna-tively contact researchonline@lshtm.ac.uk.Available under license: http://creativecommons.org/licenses/by-nc-nd/2.5/ 1 Review section: Lancet 1 Health systems development in Thailand: a solid platform for 2 successful implementation of Universal Health Coverage 3 Revised version 29 November 2017 4 5 Viroj Tangcharoensathien, PhD. IHPP, Thailand 6 Woranan Witthayapipopsakul, MSc. IHPP, Thailand 7 Warisa Panichkriangkrai, PhD. IHPP, Thailand 8 Walaiporn Patcharanarumol, PhD. IHPP, Thailand 9 Professor Dame Anne Mills, PhD. London School of Hygiene & Tropical Medicine, UK 10 11 Corresponding author 12 Viroj Tangcharoensathien, email viroj@ihpp.thaigov.net 13 14 Abstract 173 words [unstructured <150 words] 15 Body text 7934 words 16 References 113 17 Tables 5 18 Figures 5 19 Box 4 20 21 Abstract 22 Thailand’s health development since the 1970s has focused on investment in the health delivery 23 infrastructure at the district level and below, and training the health workforce. Deliberate policies 24 guided increased domestic training capacities for all cadres of health personnel and distributed them 25 to rural and underserved areas. Since 1975, targeted insurance schemes to different population 26 groups improved financial access up to when universal health coverage was implemented in 2002. 27 Despite its low GNI per capita, Thailand made a bold decision to use general taxation to finance the 28 universal coverage scheme, not relying on contributions by members. Empirical evidence shows 29 significant reduction and current low levels of out-of-pocket payments, incidence of catastrophic 30 health spending and medical impoverishment; and greatly reduced provincial gaps in child mortality. 31 Certain interventions such as antiretroviral and renal replacement therapy saved adult lives. Well-32 designed strategic purchasing contributed to efficiency, cost containment and equity. Challenges 33 remain including on preparation for an ageing society, primary NCD prevention, law enforcement to 34 prevent road traffic mortality, and effective coverage of diabetes and TB control. 35 36 37 2 Thailand: context, health achievements and challenges 38 Thailand has become internationally known for its Universal Health Coverage (UHC) policy and 39 health development successes.1 This paper reviews and analyzes the recent historical evolution of 40 health systems development focusing on the primary health care infrastructure, health workforce 41 training and distribution, and extension of financial risk protection to different target populations 42 culminating in UHC in 2002. The achievements of UHC, and factors contributing to them, are 43 analyzed. Although the six building blocks of health systems 2 are inter-linked and contribute 44 collectively to successful implementation of UHC, this paper focuses on the critical elements of the 45 health delivery system and health workforce development and financing reforms towards UHC. 46 47 The paper draws on an extensive review, analysis and synthesis of evidence from published and grey 48 literature (such as government reports) in the areas of health systems development, health 49 workforce, financial risk protection, outcomes of universal health coverage, and current health and 50 health systems challenges. Box 1 describes the search strategy for this review. Lessons drawn from 51 the review may contribute to low- and middle-income country policy makers’ understanding in their 52 quest to achieve UHC as they have committed to do in the Sustainable Development Goals. 53 54 The Kingdom of Thailand is located at the centre of the Indochina peninsula, with land bordered by 55 Myanmar, Lao PDR, Cambodia and Malaysia. The total surface area of 513,120 km2 hosts a 56 population of 68.9 million in 2017.3,4 57 58 59 60

61 62 Politics have been quite unstable, with frequent military takeovers since the democratic revolution 63 in 1932. The current military government has been in power since 2014. Political stability according 64 to the Worldwide Governance Indicators has deteriorated with the percentile rank down from 58% 65 in 1996 to 16% in 2015 [the higher the rank, the better the governance]. Ranking for control of 66 corruption is poor and deteriorated from 55% to 43% in this time. Although the government has 67 been relatively stable, its effectiveness ranked only 60% and 65% during the same period.5 68 69 Economic and health development 70 Periods of rapid economic growth between the 1960s and 1990s resulted in Gross Domestic Product 71 (GDP) growth of 7.5% per annum. However, between the 1970s and the 2000s, Thailand 72 experienced three macroeconomic crises and related structural adjustment; the first (1973--1975) 73 and second (1979--1985) oil crises and the 1997--1999 currency crisis. The second oil crisis, when oil 74 prices in 1979 rose by 131% to 29.92 USD per barrel, was longer lasting and resulted in 75 macroeconomic instability and slow GDP growth. The 1997 Asian economic crisis was triggered by 76 the collapse of Thailand’s financial stock market. It took more than a decade for GDP per capita to 77 recover to the pre-1997 level. The economic outlook has been sluggish over the last decade when 78 average GDP growth was 3.5%, although Thailand did reach upper-middle income (UMIC) status in 79 2011.6 80 81 Despite the political instability and periodically slow economy, social and health development has 82 not been negatively affected. For example, the implementation of the social agenda foreseen in the 83 4th National Economic and Social Development Plan (1977--1981) was postponed to the next (1982--84 1986) due to the fiscal squeeze.7 An IMF loan was obtained and within the health fiscal envelope for 85 the 1982-1986 plan, the government prioritised pro-rural health development to help fight poverty 86 in the context of the rise of communism in neighboring countries. Investment was focused on district 87 3 hospitals and health centres, while capital investment in provincial tertiary care hospitals was 88 frozen.8 89 90 There have been remarkable achievements over recent decades: extreme poverty has been less than 91 1% since 2004, gross enrolment in primary education has been over 95% since 1980, and universal 92 health coverage was achieved in 2002. Table 1 shows key indicators for Thailand and UMIC peers 93 (China, Malaysia, Mexico, South Africa, Turkey). 94 95 96 97 Demographic and epidemiological transition 98 Low fertility, birth and mortality rates and rapid demographic transition has resulted in the shrinking 99 of the working-age population and an increased ageing population which demands higher health and 100 social care expenditures.9 101 102 Between 1958 and 1997, infectious disease mortality declined five fold, with an annual reduction of 103 3.2 deaths per 100,000 of the population; this was largely due to reductions in malaria, tuberculosis, 104 pneumonia and gastrointestinal infections. Between 1998 and 2003, infectious disease mortality 105 increased to 70.0 per 100,000 of the population, coinciding with increased mortality from AIDS, 106 tuberculosis and pneumonia. Between 2004 and 2009, mortality declined to 41.0 per 100,000 of the 107 population, attributable to decreased AIDS mortality due to universal ART.10 Despite these 108 improvements, tuberculosis remains a major public health problem. Thailand is one of the top 109 twenty countries with a high TB burden, based on the absolute number of incident cases.11 Table 2 110 shows mortality and disease statistics 1990 to 2015. 111 112

113 114 Remaining health challenges caused by determinants beyond the health 115 sector 116 Non-communicable diseases (NCDs) accounted for 71.3% of total mortality in 2015, and demand 117 effective policy responses on primary prevention and the commercial determinants of health, in 118 particular tobacco, alcohol and unhealthy diets.12 Fast-growing markets in Asia are main targets of 119 the alcohol industry.13 Despite the significant economic burden caused by tobacco use - US$ 2.2 120 billion in 2009 (82% from productivity losses) equivalent to 0.8% of GDP or 18.2% of total health 121 expenditure 14- policy interventions against tobacco have been undermined by the industry.15–17 122 123 Across six UMIC, Thailand performed worst in adult mortality reduction with the exception of South 124 Africa (Figure 2a for males and 2b for females). Mortality from road traffic injuries (RTI) in men 125 explained the slow progress. There were 13,650 RTI deaths in 2012, and 79% were male. Taking into 126 account inaccurate classification of cause of death, WHO has estimated a total of 24,237 deaths and 127 an RTI mortality rate of 36.2 deaths per 100,000 of the population. High economic impact from RTI 128 at 3% of GDP has provoked policy and legislative action but enforcement is poor despite its 129 importance.18 Speed limits exist but enforcement was rated 3 out of 10. Enforcement of drink–130 driving was rated as medium at 6 out of 10; and 26% of road traffic deaths involved use of alcohol. 131 Enforcement of motorcycle helmets was rated 6 out of 10 and the use rate was 52% and 20% among 132 drivers and passengers respectively. Enforcement of seat-belt law was rated 6 as only 58% of drivers 133 and 54% of front seat passengers wore them. Overall, law enforcement in Thailand was rated 3 to 6, 134 compared with 8-10 in high-income countries.18 135 136 137 4 138 Mental disorders: depression, screening, treatment and suicide 139 prevention 140 Of the total 10.6 million years of Disability-Adjusted Life Years (DALY) lost in Thailand in 2013 (male 141 6.1 and female 4.5 million years), mental disorders ranked top among men, 34% of total DALYs lost 142 with a DALY rate of 23.7 per 1000 population. They ranked second among women, 21% of total 143 DALYs and 12.7 per 1000 population. Among men, alcohol dependence/harmful use, depression and 144 schizophrenia accounted for the top three conditions; while depression, dementia and schizophrenia 145 were the top three in women.19 146 147 Un-recognized and un-treated depression contributes significantly to suicide. In response to these 148 challenges, the MOPH in 2009 20 introduced integrated surveillance, prevention and treatment. 149 Using the primary care platform, the programme includes community-based depression screening 150 and severity assessment using a two-and nine-question tool. Those at-risk of severe depression are 151 confirmed and treated by general doctors in district hospitals, while nurses provide psychosocial 152 support, monitoring of relapses and prevention of suicide. 153 154 By 2016, more than 14 million people at risk of depression were screened and primary prevention 155 provided. More than 1.7 million were diagnosed and received psychosocial support; of these 0.7 156 million received antidepressants, and 0.8 million were followed up for relapse and prevention of 157 suicide. This programme increased access to standard care from 5.1% of total depressive disorders in 158 2009 to 48.5% in 2016. 159 160 The suicide prevention program has borne fruit, though there is still much to improve. In 2012, the 161 age standardized suicide rate was 11.4 per 100,000 population (male 19.1 and female 4.5). The 162 suicide rate reduction between 2000 and 2012 was 24.6% (male 22.4% and female 32%).21 163 164 165 Health systems development: a historical perspective 166 Health development since King Rama VI (1910-1925) focused on control of infectious diseases such 167 as smallpox, yaws, improved safe water and sanitation, and extension of health services through 168 outreach activities in remote areas which were gradually transformed into static facilities. At the 169 same time, successive governments established universities for training health professionals and 170 other workforce cadres.22 171 172 National socio-economic development from the 1970s 173 The 1970s Indo-China war and conflicts between communism and democracy across nations in 174 South East Asia triggered the “dominos theory” fearing that Thailand would fall under communist 175 domination. In response government policy sought to fight poverty through rural development, and 176 improved health, education, and agricultural extension services.23 Health, along with education and 177 agriculture, became cornerstones of rural development and poverty reduction.24 178 179 Health development started in the 1970s as an integral part of the five-year National Economic and 180 Social Development Plan (NESDP). A few foundation stones were laid such as a national family policy 181 in 1970 and the National Expanded Program of Immunization (EPI) in 1976. Family planning policy 182 contributed to a subsequent four decades of success in reducing the population growth rate, from 183 2.9% in 1970 to 0.3% in 2016. In other countries, such as the Philippines, family planning policy was 184 less successful than it might have been mainly due to opposition from the Church. The Philippines 185 with the same population as Thailand, of 36 million in 1970, reached 103 million in 2016 while 186 Thailand had 69 million.25,26 187 5 188 Health delivery systems development: a solid foundation 189 Large-scale investment in health infrastructure at district and sub-district levels began in 1977 during 190 the fourth NESDP.27 Full coverage of district hospitals was achieved by 1990 28 and was followed by a 191 decade of health centre development (1992-2001). By the 2000s, all sub-districts were covered by a 192 health centre. 193 194 The district health system, consisting of health centres and a district hospital, is the backbone of 195 health development. A health centre covers between 3,000 to 5,000 people, while a district hospital 196 covers between 30,000- 50,000 people. A health centre is staffed by a team of three to five nurses 197 and paramedics, and a 30-bed district hospital is staffed by three to four general practitioners, thirty 198 nurses, two to three pharmacists, one to two dentists, more than twenty paramedics and other 199 administrative staff. The size of a district hospital ranges from 30 to 150 beds based on the local 200 population size. 201 202 Nurses are critical in the health system, due to their numbers (180,000 in 2016), qualifications, 203 geographical distribution and wide-ranging contributions to public health, patient care and clinical 204 services. With additional postgraduate training, they can respond effectively to the emerging needs 205 for NCD chronic care, home care and clinical services including general anaesthesia and intensive 206 care. 207 208 The health centre, the first point of contact by the population, provides primary health care such as 209 basic treatment, prevention and health promotion through nurses and public health workers. 210 District hospitals provide more comprehensive secondary level curative services, prevention and 211 health promotion and admission facilities. Specialists, in particular covering obstetrics, internal 212 medicine, surgery and paediatrics, are available in larger district hospitals. 213 214 Historically, provincial hospitals in all provinces have offered tertiary care and received referral cases 215 from district hospitals in all clinical specialties. During the era of district health systems investment, 216 provincial hospitals received less infrastructure development support but there was a greater focus 217 on strengthening their clinical capacities through training additional specialists. 218 219 Despite rapid private sector growth at various times, including of private hospitals in the main 220 cities29, the public sector dominates the Thai health delivery system. By 2014, the Ministry of Public 221 Health (MOPH) had 67% of the 161,000 hospital beds, other public non-MOPH had 14% and private 222 hospitals had 19%. In general the private sector plays a minor role: in 2015 it contributed 14% of 223 total outpatient visits (9% at private clinics and 5% at private hospitals) and 11.3% of total 224 admissions.30 225 226 Functioning of district health systems: the development of the health 227 workforce 228 The achievement of full coverage of health services provided by the district health system was 229 accompanied by MOPH health workforce development. Adequate numbers of competent and 230 committed health workers are indispensable for a well-functioning district health system and the 231 quality services provided gained the people’s trust. Thailand’s health workforce policies integrated 232 recruitment, training, distribution and rural retention.31,32 233 234 Firstly in 1972, the MOPH introduced the policy of a three‐year mandatory rural health service 235 placement, which was enforced with all medical and nursing graduates and subsequently dentists 236 6 and pharmacists. The policy equitably enforced the same for medical graduates from private medical 237 schools. 238 239 Secondly, the MOPH introduced in 1994 a special track which recruited high school students from 240 rural and under‐served areas for medical and nursing education on condition they worked in their 241 home district upon graduation. This special track contributed to 20% of total annual national medical 242 student enrolment over the last decade and increased to 30% in 2013.33,34 Studies showed a 10% to 243 15% higher probability of staff fulfilling the three mandatory years’ service than those on the normal 244 track (accessed through a national entrance examination).35 There were also fewer annual 245 resignations in the special track than the normal track.36 Although students in the special track had 246 slightly lower examination grades at recruitment than those on the normal track, both tracks had 247 similar success rates (99.6%) in the national licensing examination for practice required for all 248 graduates.33 249 250 Thirdly, to increase medical production capacities, the MOPH strengthened its regional hospitals as 251 clinical training centres for the third to sixth clinical years of special track students.37 Students in the 252 special track study together with the normal track students during their first year of basic science, 253 and second and third year of preclinical courses. The normal track students continue their fourth to 254 sixth clinical years in the faculty of medicine of their registered university; students in the special 255 track are trained in the 37 MOPH centres. Both tracks are trained using the same curriculum and 256 instructional style, though in different institutes. Medical teachers in these centres are trained in 257 instructional skills, supervision and marking exam papers and their diplomas are conferred by 14 258 affiliated universities. Between 2000 and 2014, a total of 5,927 medical graduates from the special 259 track added significantly to the provision of rural services. Universities have greater capacity to scale 260 up basic science and preclinical training than clinical training so the MOPH clinical training centres fill 261 the gap. 262 263 Recognizing the potential of nursing, since 1946 the MOPH has compensated for the limited training 264 capacities in government universities by establishing MOPH nursing and midwifery colleges, which 265 are licensed and certified by the Thai Nurse and Midwifery Council. In 2017, there were 30 MOPH 266 nursing colleges which contributed 34% of total national graduates, while public and private 267 universities produced 37% and 29% respectively.38 To ensure adequate competencies, all nurse 268 graduates from public, private and MOPH colleges are required by the Nurse and Midwifery Council 269 to sit and pass a national nursing licensing examination since 2002. Also, all practicing nurses are 270 required to renew their license every five years based on the achievement of fifty credits of 271 Continued Professional Education. 272 273 Fifthly, the MOPH established nine public health schools to train other paramedical personnel, 274 mostly on two-year diploma courses; for example, dental public health, community public health 275 and pharmacist assistants. These diplomas filled the gaps during the rapid extension of district 276 health systems; the needs for diploma level personnel are now met and diploma courses have been 277 replaced by bachelor level courses in response to the need for improved quality and standards. 278 279 Finally, the mandatory rural service policy was accompanied by financial incentives such as a 280 hardship allowance and incentives for out-of-hours work. Non-financial incentives also played an 281 important role: annual recognition awards for dedicated front line workers were organized regularly 282 by various agencies, and the MOPH provided housing benefit in all health centres and district 283 hospitals as in-kind support to ensure 24-hour services. 284 285 Health workforce expansion was facilitated by a supportive context. Tertiary school enrolment (post-286 secondary education in universities, colleges, technical training institutes, and vocational schools) 287 7 increased for men and women respectively from 4% and 3% in 1976 to 41% and 57% in 2015. 288 Female labour force participation is high; the ratio of female to male labour force participation in 289 2015 was 78%, on a par with 76% in the OECD. 290 291 Extension of financial risk protection mechanisms 292 While ensuring the availability of a functioning service delivery system, parallel policies extended 293 financial coverage to certain groups of the population, with the application of a targeted approach.39 294 295 1975: Scheme for low-income and vulnerable populations 296 Free medical care for the poor using “means testing” was launched in 1975. The household income 297 was assessed and if it fell under a MOPH benchmark (not the national poverty line which was too 298 low), households were granted a card entitling them to free medical care at MOPH health facilities 299 with no copayment. The means testing method had a major weakness of leakage of the card to non-300 poor households while some poor households were not covered.40 The scheme was later extended 301 to the elderly, disabled and children under 12 years old. 302 303 The scheme was tax financed through an annual budget allocation to MOPH health facilities based 304 on the number of registered poor households in the catchment area. The service package covered 305 outpatient, inpatient, and dental services and medicines; a few high cost services were excluded. 306 307 1980: Civil Servant Medical Benefit Scheme (CSMBS) for the government employees 308 The non-contributory CSMBS covered government employees and their dependants well before 309 1980 when a Royal Decree was adopted. A fee-for-service reimbursement model was applied for 310 health care from the start. Services were funded by taxation to compensate for the low salaries of 311 government officials, as part of a package of social security including pension, housing benefit and 312 child allowance. The scheme covered not just government officials but also their dependants 313 including parents, spouse and children under 18 years old. 314 315 1983: Voluntary health insurance for the informal sector 316 In 1983, the MOPH initiated the Health Card Project - a voluntary community-based health insurance 317 - with an annual premium of 500 Baht (or US$ 20 at that time) per household (up to five members). 318 The benefit package was comparable to the Low-Income Scheme. The main weakness was adverse 319 selection, whereby members mostly consisted of the chronically ill and high users of services, while 320 healthy members did not buy the card. In 1994, to increase enrolment, this scheme became a 321 publicly-subsidized voluntary insurance scheme and the MOPH added 500 Baht per card.41 Despite 322 the additional income, the scheme was financially non-viable with expenditure exceeding revenue. 323 Spill over benefits included increased MOPH capacity in managing insurance funds, registration, fund 324 allocation and monitoring and evaluation. 325 326 1990: Social Health Insurance for private sector employees 327 In 1990 the Social Security Act was passed, covering private sector employees. Social Health 328 Insurance (SHI) was a component of a comprehensive social security system including pension, 329 disability compensation and funeral grants. SHI is financed by equal tripartite contributions from a 330 payroll tax paid by employers, employees and the government. The Social Security Office (SSO) 331 purchased a comprehensive set of services including outpatient, inpatient and high cost services 332 from existing public and private hospitals using a single capitation payment. This was the first time 333 that capitation payment had been applied in Thailand, and in general it was well received by public 334 and private hospitals and appeared to provide decent quality of care to members.42 Thus SHI set the 335 precedent of a capitation contract model, which UHC later built on by adopting capitation payment 336 for outpatient care and Diagnostic Related Groups (DRG) payment within a global budget for 337 inpatient care 43 (this dual payment system has now been introduced in the SHI). 338 8 339 Figure 3 shows the developments over time in health infrastructure expansion and financial risk 340 protection mapped against the reduction in under-five mortality between 1970 and 2010. 341 342

343 344 Political window of opportunity for UHC in 2001 345 Different targeting approaches resulted in variations in the design of benefit packages and 346 purchasing methods, resulting in inefficiency and inequity. Despite multiple efforts, 30% of the 347 population were still uninsured by 2001. A Universal Health Coverage Scheme (UCS) was featured in 348 the political manifesto of the January 2001 general election campaign. After victory, the Thai Rak 349 Thai led government-piloted implementation of the UCS in six provinces in April 2001, and rolled it 350 out nationwide by April 2002.44 At this time the GNI per capita was not high, US$ 1,990, and the 351 fiscal space was low - government tax amounted to 13% of GDP. In parallel, a legislative process 352 enacted the 2002 National Health Security Act in November 2002.45 353 354 Thai people referred to the UCS as the “30 Baht” Scheme, reflecting the political slogan “30 Baht 355 treats all diseases” used to promote the Scheme and highlight the comprehensiveness of the benefit 356 package. Thirty Baht (approximately US$ 1) was the copayment for an outpatient visit or an 357 admission paid by the non-poor. 358 359 The UCS was established to cover members of the Low Income Scheme, Health Card Scheme and the 360 30% uninsured and was managed by the National Health Security Office (NHSO), a statutory agency 361 established by the Act. The UCS, CSMBS and SHI collectively comprise the UHC, though there is 362 some variation in their design features (Table 3). 363 364

365 366 The UHC trajectory is demonstrated in Figure 4. Populations are classified into three layers: poor and 367 vulnerable groups at the bottom, government and private sector employees at the top and the large 368 informal sector in the middle.46 To keep the promises to the electorate, political decisions endorsed 369 the reformists’ recommendation to finance the UCS by general tax. Enforcing premium payment by 370 the large informal sector with their irregular income was neither technically feasible nor politically 371 palatable; while resource needs for the UCS were within government fiscal capacity. At the UCS 372 inception in 2002, total estimated resource requirements for 47 million members were THB 56.5 373 billion. The existing MOPH pooled budget for health services provided THB 26.5 billion, and the 374 Prime Minister had the leadership ability and capacity to mobilize the shortfall of THB 30 billion from 375 tax funding. 376 377 The decision to adopt closed-end budgets (per capita budgets based on unit cost and utilization rates 378 of different types of services, and service reimbursement through capitation and DRG payment 379 within a global budget) facilitated projection of total funding needs and hence assessment of 380 financial feasibility.47 381 382

383 384 UHC was at heart a political decision; success has been attributed to a ‘big bang’ policy reform, led 385 by a populist government; and to the established institutional capacity mobilised by reformists who 386 were technocrats in the MOPH influencing political decisions based on evidence-based knowledge, 387 previous practical experience and institutional networks.48 388 389 9 An understanding of political economy is critical in understanding policy change, in other words the 390 political processes in adopting, achieving and sustaining UHC in the context of competing interests 391 amongst actors.49 Box 2 provides several examples where decisions required conflicting interests and 392 tensions among key players to be carefully managed. The examples also demonstrate the 393 importance of political leadership and provision of evidence. 394 395 396 397 Successful implementation benefited from supply side capacity.54 In addition, rapid implementation 398 was made possible by the Civil Registration and Vital Statistics (CRVS) system, established since 399 1956. This mandates registering all births and deaths and assigns a unique citizen ID number to 400 everyone, making it possible to identify all UCS members and require them to register with a 401 preferred provider network. In addition, this facilitates transfer of members across the three public 402 insurance schemes to ensure seamless continuity of health coverage. For example, SHI members 403 who become unemployed are automatically transferred to UCS; vice versa, UCS members once 404 employed are transferred to SHI. 405 406 In summary, improved fiscal space from economic development, political leadership and 407 commitment and health systems readiness were enabling factors for the adoption and successful 408 implementation of the UCS. 409 410 Ensuring accountability and responsiveness of UHC 411 Previous decades of health system development had ensured services were available to respond to 412 the health care demands which would arise from UHC, and design features ensured cost control. 413 Critical features of any UHC design also include processes for accountability across stakeholders and 414 responsiveness to citizens, to ensure the continuing society-wide support and trust needed for UHC 415 to survive into the longer term. 416 417 Split role between purchasers and healthcare providers increases accountability 418 Both the SHI and CSMBS had split the roles of purchaser and provider from the beginning. The Low 419 Income Scheme and Health Card Project applied an integrated model with the MOPH serving roles of 420 both purchasing and service provision, and this was considered to be less responsive than other 421 models.55 For the UCS, the National Health Security Office (NHSO) purchased services from public 422 and private provider networks (though mostly MOPH provider networks due to their geographical 423 monopoly of district health systems in rural areas) through annual contractual agreements using the 424 dual payment system of capitation and DRGs. UCS completely separated the two functions from the 425 previous single MOPH administrative entity56, and meant that the NHSO could purchase services 426 uninfluenced by provider self-interest. Capitation payment linked with the number of registered 427 members, a call centre for grievance management and disputes settlement, and the annual public 428 hearing for UCS members are designed by NHSO to increase healthcare provider accountability to 429 UCS members. 430 431 From our analysis, the decision to split the two MOPH functions was a political decision. The SHI had 432 set the precedent, since 1991, as a purchaser organization negotiating and purchasing services from 433 existing public and private providers on an equal footing. In contrast the MOPH, which managed the 434 low income and voluntary health insurance scheme, was perceived by private providers to face a 435 conflict of interest and to favour contracting its own providers. Also the MOPH is mandated as a 436 regulatory agency, setting norms and standards and with a policy formulation and oversight role 437 rather than a purchaser role. 438 439 Financial accountability framework 440 10 The MOPH annual budget allocations for service provision at sub-district, district and provincial 441 levels were terminated and integrated into the UCS budget managed by the NHSO.41 This supported 442 the clarity of accountability between purchasers and providers, as MOPH and other public hospital 443 revenues were generated only from service provision to members of the three insurance schemes, 444 encouraging providers to be responsive to patients. Also the same rates of capitation and DRG 445 payment (which included health worker salaries) was applied to purchasing services from the private 446 sector. The level playing field in purchasing services across public and private providers smoothed 447 the implementation of the reform and gained private sector collaboration. 448 449 Budgeting: role of evidence, participation and transparency 450 The per capita budgeting applied by NHSO for the UCS significantly changed the budgeting system. 451 From the start of the UCS, the budget was estimated based on unit costs and utilization rates of 452 different services and this principle is still applied. Cost and use rates are projected for the budget 453 year. Unit cost includes labour, medicines, supplies and depreciation of major equipment. The total 454 budget request is the multiplication of per capita budget and the UCS population. The Bureau of 455 Budget cannot exercise its discretionary power as before, given the evidence of costs and utilization. 456 The multi-stakeholder membership of the Budgeting Subcommittee appointed by the National 457 Health Security Board has balanced power, as the Bureau of Budget is one of the members. All 458 members have equal influence and use evidence to make recommendations. 459 460 A further example of use of evidence to support budget requests is the use of health technology 461 assessment. Thailand strengthened and sustained its institutional capacity in health technology 462 assessment through creating the Health Intervention and Technology Assessment Program57, whose 463 role has included prioritizing the inclusion of new medicines into the National List of Essential 464 Medicines, and new interventions into the UCS benefit package.58 465 466 The role of primary health care (PHC) in UHC 467 The strong public health, primary care, efficiency and equity orientation of UHC was driven by an 468 exceptionally strong cadre of public health experts who have been influential health technocrats. 469 Investment by the MoPH in postgraduate training in key health policy and systems areas using WHO 470 and other funding sources yielded high pay-off when all returned to Thailand and served in positions 471 of influence.59 Continuing capacity development in health systems and policy research supported 472 evidence based health reforms.60–62 Developments in district health systems and PHC were further 473 encouraged by a self-help social movement developing and supporting district public health leaders, 474 some of whom later became prominent national public health leaders; see box 3. 475 476 477 478 479 The well functioning PHC system developed in Thailand was the foundation for implementing UHC 480 and achieving the health MDGs well before the target date of 2015.66 PHC and UHC (SDG 3.8) are 481 designed to achieve the maternal and child health targets in SDG 3.1 and 3.2, and facilitate access to 482 reproductive health services including family planning (SDG 3.7). Thailand has eliminated vertical 483 transmission of HIV through PMTCT67, and the high coverage of universal ART indicates the 484 likelihood of ending the AIDS epidemic as a public health threat by 2030 (SDG3.3), though it still 485 faces challenges in ending TB as a major public health threat. NHSO strategic purchasing helps the 486 PHC system enhance its detection, screening, prevention and effective coverage of several NCDs, 487 including through diabetes, hypertension and cervical cancer screening. 488 489 However, achieving the NCD mortality targets (SDG 3.4) requires the whole of government, not the 490 MOPH alone, to counteract the strong influence of commercial determinants and the resistance 491 11 from tobacco (SDG3.a), alcohol (SDG3.5) and unhealthy food industries. This requires policy 492 coherence across government sectors and effective multisectoral action for health. The health 493 service sector, though critical, is not adequate to achieve this SDG target when determinants are 494 outside the direct command and control of the health sector. The MOPH must have the capacity to 495 ensure a health lens is adopted in government and private sector policies. 496 497 UHC achievements 498 499 Improved level and distribution of health service utilization 500 The UCS reduces the probability of its members going without formal ambulatory care when sick by 501 3.2 percentage points (PPT).68 UCS increases the probability of using outpatient care at public service 502 providers by 2.7 PPT (5%) and of hospitalization to a public hospital by 1 PPT (18%); these effects are 503 largest among elderly people. 504 505 Another study69 shows that UHC increases the likelihood of having annual check-ups, in particular for 506 women, and increases access to hospitalization by over 2% and outpatient visits by 13%. No 507 evidence is noted of moral hazard such as increased unhealthy behaviour or reduced preventive 508 efforts. Beyond improved access to care, higher utilization favours the poorest people and this is 509 shown clearly in benefit incidence analysis.70 Benefit incidence - assessing whether the government 510 budget benefits more the rich or the poor - is pro-poor due to higher utilization by the poorest than 511 the richest wealth quintiles, especially at health centres and district hospitals. 512 513 Another aspect of utilization is the low prevalence of unmet healthcare needs. The nationally 514 representative household survey on unmet needs, conducted by the National Statistical Office71, 515 reports low prevalence of unmet needs for both outpatient and inpatients on a par with OECD 516 peers.72 The extension of renal replacement therapy into the UCS benefit package in 2008 has 517 improved equitable access to services, saved lives and deepened financial risk protection (see Box 4). 518 519 520 521 Factors that contribute to pro-poor outcomes for both utilization and benefit incidence include the 522 extensive geographical distribution of a well-functioning close-to-client district health system75 (the 523 provider for UCS members) and the comprehensive benefit package free at the point of service. By 524 2016, the use rate among UCS members had reached 3.5 visits per capita per year, and 0.13 hospital 525 discharges per capita per year with an average length of stay of 4.1 days. These utilization rates are 526 similar to a few of the OECD countries.76 527 528 Very often the district health system is the only provider in the district with whom the NHSO can 529 contract. Strict quality conditions such as accreditation status cannot be applied where there is a 530 geographical monopoly. The Healthcare Accreditation Institute has developed step-wise quality 531 improvement processes since 2003. In 2007 the NHSO offered step-wise financial incentives, which 532 were higher for accredited hospitals and lower for those in the process of quality improvement. By 533 2012, almost all hospitals were accredited or had quality assurance processes well in place.77 534 535 Equity in health financing and financial risk protection 536 General tax, the sole source of financing UCS, is the most progressive financing source as the rich 537 contribute a higher proportion of their income to taxes than the poor.78 A comprehensive benefit 538 package and services free-at-the-point-of-use have resulted in reduced household out-of-pocket 539 payments (OOP), from 34% of Total Health Expenditure in 2000 (prior to UCS) to 12% in 2014.4 540 541 12 The lower the OOP, the lower the prevalence of households facing catastrophic health expenditure 542 is.79 The Thai UCS has reduced the probability of catastrophic health expenditure, defined as 543 households spending on health more than 10% of total household spending, and there has been a 544 greater reduction of OOP spending among high-income households. UCS provides a safety net to all 545 people including the rich. 68 546 547 UHC as a whole (including all three insurance schemes) has reduced the prevalence of households 548 facing catastrophic health expenditure and medical impoverishment.80 A counter-factual scenario 549 estimated that without the 2002 UCS, a total of 100,604 households nationwide would have been 550 impoverished by out-of-pocket payments for health in 2008. UCS had reduced the number of health-551 impoverished households by 37,628 or 37.4%.81 552 553 The chronology of coverage extension to certain high-cost services, as described in Table 4, has 554 contributed to deepening financial risk protection. Inclusion of these new interventions was 555 accompanied by increased financial allocations. Certain cost-effective interventions, such as dental 556 root implants, are still not covered as these services are available only in certain urban centres and 557 so access would be inequitable. 558 559

560 561 Relative to countries comparable to Thailand in terms of economic performance, health financing 562 and outcomes, UHC reduced out-of-pocket payments by 13 percentage points of total health 563 expenditure, and increased annual government per capita spending on health by US$ 79. This 564 amount is worthwhile if financial risk protection for households is a societal goal. In terms of macro-565 economic impact, UCS had a small effect of an extra US$ 60.8 on the total health expenditure per 566 capita and did not appear to have affected the size of GDP or the share of the government budget 567 devoted to health.82 568 569 Efficiency and cost containment 570 Although UCS employed mixed provider payment methods, the main mode for over 90% of 571 payments was closed-end payment (capitation and DRG payment within a global budget); the 572 remainder were based on fixed fee schedules for certain services such as dialysis and other high-cost 573 interventions. Closed-end payments contain cost and can provide incentives for increased efficiency 574 as they limit the opportunity for supplier-induced demand. Capitation disciplines providers to 575 prescribe items in the National List of Essential Medicines (NLEM) for UCS members, while fee for 576 service payment in the CSMBS influences them to prescribe drugs outside the NLEM - these 577 comprise up to 41% of total prescriptions and 67% of outpatient medicines expenditure in the 578 CSMBS.83 579 580 The NHSO is able to assert monopsonistic purchasing power, since it is a large purchaser and can 581 negotiate prices with assured quality from domestic and international suppliers for example for 582 cataract lenses, medical devices and certain medicines such as erythropoietin, even from sole source 583 producers. Table 5 shows cost savings estimated from the difference between market and 584 negotiated prices and actual volumes purchased. The total savings of US$ 188 million are significant 585 and make it possible to provide more services for UCS patients. 586 587

588 589 A risk in a system where expenditure is strictly controlled by the government through global budgets 590 is that health expenditure is not allowed to rise to match increasing demands and benefit package 591 extension. While it is not easy to assess appropriate levels of expenditure, the continuously 592 13 increasing government allocation to the UCS, reflecting the extension of the benefit package, 593 increased utilization, and general price and wage inflation, does suggest that funding kept pace with 594 increasing requirements (Figure 5). 595 596

597 598 Health gain 599 Gruber et al84 in their assessment of the impact of UHC using mortality statistics from all provinces 600 between 2000 and 2002, and regression analysis of the impact of increased access to health services 601 under UCS, reported a sharp equalization of infant mortality rates across provinces. This was 602 consistent with the increased access to medical services for the poor leading to a reduction in infant 603 mortality rates. 604 605 Assessment of mortality change between 2001 (when UHC started to be introduced) and 2014 using 606 mixed effects modeling to test whether the slopes of Standardized Mortality Ratio across super-607 districts were equal showed a steady decline of all cause mortality, though with a varying degree of 608 reduction in the inequality of adult mortality across geographical areas.85 609 610 UCS members’ satisfaction and concerns: monitoring for improvement 611 The satisfaction survey conducted annually by an independent agency since 2003 shows high level of 612 satisfaction amongst UCS members - 8 out of 10. Provider satisfaction was lower at 6.2 in 2003, but 613 increased to 7.6 in 2010 and has been sustained.86 Main causes of patient concern are long waiting 614 time and service quality while providers are worried about lack of financial and human resources to 615 meet patients’ high expectations. 616 617 Unmet health care needs are low: 1.4% and 0.4% for out‐ and in‐patient care in 201071 and 1.5% and 618 0.1% in 2015.87 Reasons for unmet needs are long waiting times for outpatients, and geographical 619 barriers for inpatient care. 620 621 Challenges and solutions 622 Achieving UHC has not been without its difficulties for Thailand. The first challenge was to manage 623 the survival of the UCS financing model throughout a turbulent political climate. Between 2001 and 624 2015, UCS survived eight rival governments, six elections, two coup d’états and thirteen health 625 ministers. Political analysts foresee continued protracted conflicts in the current climate. Despite 626 political turmoil, GDP growth fluctuation and the economic crisis in 2009, the total UCS budget 627 continually increased. UCS has gradually become owned by the people, not the political party which 628 initiated it. Its positive impact on improved access and financial protection of households has meant 629 that governments from all parties have continued support.45 630 631 Finding ways to make budget decision-making more transparent, participatory and therefore 632 effective has played a part in meeting the challenge. Not only is the annual budget prepared based 633 on evidence of service utilization and unit cost, but also civil society representatives in the National 634 Health Security Board help safeguard the interests of UCS members, and national media publicity on 635 annual budget processes helps support continued funding of the UCS. 636 637 The termination of supply side financing previously managed by the MOPH has led to protracted 638 conflict between the MOPH and the NHSO. For example, as a monopsonistic purchaser, NHSO has 639 been able to drive down the purchase price of medical products while ensuring quality. This has 640 reduced the profit margin of suppliers and been unpopular with a few right wing conservatives in the 641 14 Medical Council and Private Hospital Association and led to claims of corruption in NHSO purchasing 642 of medical products, which have been proved untrue.88 643 644 However, not all planned UCS developments have proved possible. In particular, slow progress was 645 made addressing the segmentation of the insurance schemes. The National Health Security Act of 646 2002 provided for harmonisation of the schemes, and progress has indeed been made between the 647 UCS and SHI in harmonising the benefit package and using closed-end provider payment. But the 648 CSMBS remains problematic, in particular the cost escalation and inefficiency generated from fee for 649 service payment for outpatient services. For inpatients, CSMBS applies multiple bands of DRG 650 payment favouring of tertiary and teaching hospitals over other hospitals for clinical conditions of 651 similar case mix and severity. This different payment system is an important explanation for why 652 expenditure per capita in the CSMBS is four times higher than for the UCS. Reform of the fee-for-653 service outpatient reimbursement system in the CSMBS has been retarded by resistance from 654 healthcare providers and conflicts of interests in prescribing medicines89, in a context of weak 655 governance by the Comptroller General Department. 656 657 The second challenge relates to the health workforce in the context of the advent of the ASEAN 658 Economic Community (AEC) in 2015 which has facilitated people, labour and capital movements 659 across ASEAN member states’ borders, global medical tourism, and health worker retention in a 660 global market for health workers. The density of doctors, nurses and midwives between 2007 and 661 2013 was 24.7 per 10,000 population90, slightly above the threshold of 22.8 defined as adequate91, 662 but below the proposed threshold of 34.5 of the International Labour Organization.92 Ageing and 663 chronic diseases put pressure on the health workforce; the current density is vulnerable to 664 shortages. Although the AEC does not have immediate effects on the out-migration of health 665 workers, there is need to continue monitoring its implications. 666 667 Evidence from the Thai Nurse Cohort indicated that in 2012, 15.4% of the cohort intended to leave 668 their nursing career in the next two years,93 an increase from 11.2% in 2009. Shorter retention in the 669 profession has major implications for nurse shortages, and transformative health professional 670 education is being implemented through reforms to the curriculum and instruction methods so that 671 graduates are responsive to the emerging health needs of people. 672 673 International out-migration of Thai doctors and nurses is not common94, but international patients 674 seeking hospital care in Thailand, so called medical tourism, is more common and has implications 675 for demand for doctors and other medical personnel. There are conflicting estimates for annual 676 international patients: a high estimate of 8.3 to 9.5 million visits in 201095 and a low estimate of 677 0.515 million visits in the same year which would have limited impact on the health workforce.96 A 678 recent phenomenon is retirement of Japanese to Thailand: its impact on demand for health services 679 and the health workforce is so far minimal though numbers are increasing.97 680 681 The third challenge relates to ensuring policy coherence and effective multi-sectoral action from 682 both health and non-health sectors in order to respond to the health challenges arising from 683 demographic and epidemiological transitions and economic development. Promoting healthy ageing 684 and the development of community-based and social care for the elderly is at an early stage of policy 685 development.98 The epidemiological transition towards NCDs99, technological progress and increased 686 expectations from citizens for expensive new interventions add pressure for more resources.100 687 NCDs in Thailand claim 75% of disability adjusted life years lost and give rise to US$ 404 million 688 annual economic losses.101,102 Primary prevention requires bold government leadership to address 689 the commercial determinants, in particular tobacco, alcohol and obesogenic food industries. The 690 best buy interventions for tobacco and alcohol have yet to be scaled up in Thailand, in particular 691 15 relating to prices and taxation.103,104 The stagnation of high mortality from road traffic injuries 692 requires stronger law enforcement and a comprehensive package of interventions. 693 694 Fighting commercial interests and protecting health of the population requires strong ethical 695 leadership and active citizenry guided by evidence, witness recent events concerning breast-milk 696 substitutes. Concerns over the low level of exclusive breast feeding for the first six month in 697 newborns, 23% in 2016105, and the repeated violations of the International Code of Marketing of 698 Breast-milk Substitutes106 by the formula milk industry, led to government efforts to make the 699 voluntary Code a national Law. In the public hearings of the MOPH-proposed draft Bill, there was 700 strong resistance from certain pediatricians and the Medical Council who amplified the downsides of 701 breast feeding by quoting a study in Nepal107 that “prolonged breast feeding beyond 12 months 702 results in stunting”. This concealed the multiple factors contributing to stunting such as socio-703 economic status, maternal education, poverty, and inadequate and inappropriate supplementary 704 feeding practices.108 The WHO Director General’s strong advocacy for the Thai law with the Prime 705 Minister influenced the National Legislative Council consensus vote for the draft Bill. 706 707 Management of diabetes mellitus is a particular problem. Diabetes prevalence in adults (>15 years) 708 increased from 6.9% in 2009,109 to 8.9% in 2014 (males 7.9%, females 9.8%).110 Of further concern is 709 the low level of effective coverage of diabetes management: in 2014, 43.1% of diabetic patients 710 were un-diagnosed; 2.7% of those medically diagnosed were not on treatment; and only 43% of 711 treated patients were well controlled (fasting blood sugar <130 mg/dl). Overall, only 23.5% of 712 diabetes patients were well controlled. The effective coverage in 2009 was better than in 2014; 713 undiagnosed was 31.2%, and overall well controlled was 30.6%. 714 715 Increased incidence of End Stage Renal Diseases (ESRD) due to inadequate control of diabetes and 716 hypertension has put pressure on the Renal Replacement Therapy (RRT) budget. This has prompted 717 serious policy intervention by the MOPH, on urine test screening by Village Health Volunteers and 718 laboratory confirmation by district hospitals, screening of diabetic retinopathy to ensure prompt 719 treatment, and identification and treatment of Chronic Kidney Disease (CKD) in order to delay 720 progression of CKD to ESRD.111 721 722 The fourth challenge concerns tuberculosis. Despite good progress in controlling infectious 723 diseases112, in 2015 there were 117,000 new tuberculosis cases and 12,000 deaths.113 Thailand is 724 listed as one of the 30 high burden countries for TB, TB and HIV, and MDR-TB. The complexity of 725 case finding, contact tracing and successful treatment is challenging in highly mobile populations 726 including migrants who have high TB prevalence. 727 728 729 Conclusions and lessons 730 731 Empirical evidence has demonstrated the significant progress and achievements of Thailand’s UCS. 732 Increased fiscal space from favourable economic growth (even with some interruptions), when 733 matched with political and financial commitments to health development, ensured favourable 734 resources for health infrastructure and health workforce development. The five-year planning 735 process ensured long term policy continuity despite short-lived governments. Full geographical 736 coverage of functioning primary health care within a district health system provided a solid 737 foundation for implementing UHC. Though over time, benefit packages have been harmonised to 738 reduce the extent of fragmentation and inequity across the three schemes, there remain large 739 differences in expenditure per capita and CSMBS payment reform faces serious resistance from 740 healthcare providers. 741 742 16 Although most countries target various population groups using different sources of finance, the last 743 phase of achieving UHC is usually to cover the uninsured population who are mostly engaged in the 744 informal sector. This needs an informed and bold political decision on the financing choice between 745 voluntary contributions and general taxation. A choice in favour of general taxation must be 746 supported by adequate fiscal space and political commitment to increase the fiscal space for health. 747 The choice in favour of a contributory scheme needs enforcement and administrative capacity to 748 collect premiums; with this approach it may take a few decades to reach UHC due to the large size of 749 the informal sector in developing countries. Thailand made the decision in 2002 to use general 750 taxation, despite its small GNI per capita of US$ 1,990 and tax revenue at 13% of GDP. UHC was 751 financially feasible because closed-end payment from the start contained costs effectively. 752 753 In addition to the inheritance of a solid platform of health delivery, the system whereby the NHSO 754 contracts a PHC network has resulted in pro-poor utilization and benefit incidence. Closed-end 755 payment has enabled cost containment and improved efficiency; a comprehensive benefit package 756 and extension to high-cost but cost-effective interventions has deepened risk protection and 757 resulted in low prevalence of catastrophic spending and impoverishment due to health care costs. 758 759 760 Lessons learned from Thailand’s UHC 1. Extensive geographical coverage of functioning PHC provides a solid platform for implementing UHC. 2. Rural recruitment, home town placement, financial and non-financial incentives can improve the availability of health workers in underserved areas and strengthen PHC. 3. The district health system is a strategic hub for translating UHC policy into pro-poor utilization and benefit incidence. 4. Tax-financed UCS proved the most feasible and progressive route to achieve UHC in the context of large informal sector. 5. A comprehensive benefit package, with minimal copayment at the point of service, prevents catastrophic health spending and protects households from being impoverished. 6. A well designed strategic purchasing organization and provider payment methods support efficiency, cost containment and equity outcomes. 7. Stringent health technology assessment for inclusion of new medicines and interventions into the benefit package enhances health systems efficiency. 8. An understanding of the political economy of health and the importance of good governance, an active citizenry and civil society, provision of evidence and ethical leadership helps manage tensions and conflicts and safeguard the interests of UCS members. 761 762 17 Acknowledgement 763 The authors acknowledge all MOPH predecessors who contributed to policy formulation, and health 764 workers at the front line and hospitals who have untiringly implemented health programs since the 765 1970s which have benefited the Thai population. They brought the Thai health systems and UHC to 766 the attention of the world. We pay tribute to the late Dr Sanguan Nittayaramphong for his UHC 767 leadership and to all other “unsung heroes”. 768 769 Funding 770 No financial support for this work. 771 772 Contributions 773 All authors contributed to and agreed with the conceptual framework of this review, VT provided 774 the first draft, all authors commented and strengthened the text and signed off the final draft. AM is 775 the guarantor of this paper. 776 777 Conflict of interest 778 Declared none 779 780 781 18 References 782 1. Kim JY. Speech by World Bank Group President Jim Yong Kim on Universal Health Coverage in 783 Emerging Economies. 2014. https://goo.gl/Uc9wWu (accessed 28 October 2017). 784 2. World Health Organization. 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How to prevent progression to end stage renal 1075 disease. J Ren Care 2007;33(3):105-7. 1076 112. Aungkulanon S, Kusreesakul K, Kunnathum J, Bundhamcharoen K. Decreasing the burden of 1077 infectious disease in Thailand. Lancet 2013;381(S11):S24 1078 113. Regional Office for South-East Asia. Bending the curve - ending TB: Annual report 2017. India: 1079 World Health Organization; 2017. 1080 Box 1 Search strategy of literature used by this review Literature was searched for systematically, framed under the main objectives of the paper: how health systems development has contributed to the implementation of UHC, what are the UHC outcomes, what have been the processes of expansion of financial risk protection to different population groups up to when the whole population was covered. Using Google scholar search, we retrieved literature relate to health systems development with a specific focus on health delivery systems, PHC development, health workforce training and retention. We retrieved both published and grey literature in English and the Thai language. Literature related to socio-economic development, burden of disease, NCD challenges, alcohol and road safety, adult mortality and the contextual background were searched for and synthesized from World Heath Statistics, and global reports such as for TB, road safety, and NCDs. World Development Indicators were used for international comparisons. Evidence related to outcomes of UHC and UCS was retrieved only from peer reviewed published literature, and were scrutinized for quality of analysis prior to use. Box 2 The political economy of UCS: achievements amidst tensions and conflicts. The benefit package initially excluded renal replacement therapy (RRT) because of its high cost and lack of capacity to deliver services equitably. The government decided to include RRT in the UCS package although it was relatively less cost effective, at four times the indicative benchmark of one GNI per capita per Quality Adjusted Life Year gain50,51; the budget impact was high due to high and increasing prevalence. Inclusion was a political decision based on ethical and equity concerns: CSMBS and SHI members, having higher social status, job security and employment, already had full access to RRT. The cost of dialysis--US$ 7,000 per patient year – caused UCS patients and their families to incur catastrophic expenditure.52 Most patients died from sub-optimum treatment when they could no longer sell assets or borrow further. Given the evidence, and backed by a coalition of nephrologists, civil society organizations, and an End Stage Renal Disease patient group, Minister of Health Mongkol Na Songkhla, as chair of NHSO Board, boldly submitted and gained Cabinet approval for full subsidy of RRT53, based on a ‘PD (Peritoneal Dialysis)’ First policy (see Box 4). The Private Hospital Association was very unhappy with the PD First policy, since NHSO centrally negotiated the prices of supplies whereas hospitals could generate profit from Haeomodialysis (HD). Reformists argued that as HD will be provided for patients who fail PD, for example because of complications from peritonitis, there was a market for private HD centres. With strong political leadership, the Minister of Health made a firm decision for PD First against commercial interests. Strategic purchasing adopted by the NHSO, despite the efficiency and equity advantages, created tensions among actors. First, closed-end payment such as capitation and DRG under global budget was unpopular with providers who favoured fee for service payment similar to the CSMBS outpatient payment, as more diagnostics and non-essential medicines could be provided. Fee for service also can boost pharmaceutical and diagnostic markets. Second, the hospitals’ gaming of NHSO by falsely reporting complications and co-morbidity to gain higher payment for inpatient care was checked by NHSO’s stringent audits which required over-claimed amounts to be return to NHSO. Third, despite significant cost savings and assured quality of medical products procured through NHSO monopsonistic bargaining (see Table 5), it was unpopular both with hospitals who might benefit from their own purchases and medical device and pharmaceutical companies who could gain higher margins from selling to hospitals rather than to NHSO. These tensions resulted in a recent interpretation by the Auditor General Office that the NHSO has no legal mandate to exercise monopsonistic purchaser power. To sustain the good performance of UCS, NHSO, civil society and active citizens need to collectively steer and balance different interests to safeguard the interest of UCS members. Most importantly, politicians must have ethical leadership and be free from conflict of interest. Evidence on positive outcomes of UCS such as enhanced financial risk protection, number of lives saved, reduced inequitable mortality gap is powerful and needs to be made known to politicians and legislative bodies. Box 3 The Rural Doctors Society The Rural Doctors Society, known as the Rose Garden group after the hotel where it meets, was established in 1978 as a self help group for district health systems and PHC development63; it coincided with the 1978 Alma Ata movement. Convened monthly for the last thirty years, it is an informal policy group, closely linked with civil society, where various policy agendas were generated 64 such as the anti-tobacco campaign, Universal Health Coverage, the Sin Tax Health Promotion Fund and the Health Systems Research Institute. The Society’s early mandate was collective support and it convened an annual conference. Four years later, the Rural Doctors Foundation was established and an annual Best Rural Doctor Award was conferred on the most dedicated doctors in remote or underserved areas. This has become a prestigious award which gives social recognition to rural doctors and promotes rural retention; it has been followed by similar recognition of several other professional cadres. Since completion of the district hospital network, the Society has expanded its role to political advocacy and oversight. In the IMF package related to the 1997 Economic Crisis, the MOPH earmarked 1.4 billion THB for medicines procurement. The Rural Doctors Society, the Rural Pharmacists Forum, NGOs, and the Drug Study Group and Consumer Protection Group formed a coalition of 30 organizations against corruption, and exposed a scandal associated with the medicines procurement. This resulted in a fifteen-year term of imprisonment for a Public Health Minister who found guilty in November 2004 of accepting bribes from drug companies. The corrupt senior officials were dismissed and their pension benefits suspended.65 Box 4 Thailand’s Peritoneal Dialysis (PD) First policy: outcomes and challenges Thailand has seen the world’s fastest increase in RRT treatment, with a 120% increase in the number of treated ESRD patients, from 100.3 per million population (PMP) in 2008 to 220.2 PMP in 2013.73 The UCS has prolonged the lives of nearly 50,000 ESRD patients since 2008.74 The main challenge is the increased incidence and poor control of diabetes and hypertension which are key determinants of ESRD. Between 2000 and 2012, Thailand has experienced rapid increases in diabetes-related ESRD and the highest increase in ESRD prevalence in the world, from 98 to 1,097 PMP. Kidney transplantation performs poorly in Thailand due to a donor shortage. The PD First policy had explicit goals of achieving efficiency and equity, as patients can manage at home with no travelling costs, compared to three HD sessions a week at a provincial city which is not accessible for poor rural people. Also NHSO can better contain the costs of PD through national negotiation of solution costs, while HD is labour intensive and vulnerable to increasing labour costs. 1 Figure 1 Map of Thailand 2 Figure 2a Adult mortality rate of 15-60 year-old males (per 1,000 males) for Thailand and five upper-middle income peers Figure 2b Adult mortality rate of 15-60 year-old females (per 1,000 females) for Thailand and five upper-middle income peers 3 Figure 3 Two strands of health system development, a) delivery and health workforce, b) financial protection, 1970-2010, and trend in under-five mortality reduction Source: Reference 23 4 Figure 4 Trajectory for achieving UHC Source: Reference 46 with some modifications Top layer: formal public private sector employees and dependents Middle layer: informal sector, borderline poor & non-poor Bottom layer: vulnerable people and the poor measured by poverty or other arbitrary measures Tax financed CSMBS; Payroll tax, tripartite contributory Social Health Insurance Tax financed UCS (Subsidize Community Based Health Insurance in the past) Tax financed UCS (Low income card scheme in the past) Expand from the TOP Expand from the BOTTOM 24% of population 65% of population 11% of population 5 Figure 5 Continued political commitment to UCS: annual budget, across rival governments, 2002-2017 Note: TRT denotes Thai Rak Thai party, Mil denotes military government, PPP denotes People's Power party, DP denotes Democrat party and PT denotes Pheu Thai party 1 Table 1 At a glance, Thailand and five upper-middle income peers China Malaysia Mexico South Africa Thailand Turkey Economic and fiscal space • GDP per capita (current US$), 2016 8,123 9,503 8,201 5,274 5,908 10,788 • GDP growth (annual %), 2016 6.7 4.2 2.3 0.3 3.2 2.9 • Revenue, excluding grants (% of GDP) 15.8 (2014) 18.9 (2015) .. 31.5 (2015) 20.7 (2015) 32.4 (2015) • Tax revenue (% of GDP) 9.7 (2014) 14.3 (2015) .. 27.3 (2015) 16.3 (2015) 18.2 (2015) Demography • Population, total (millions), 2016 1,379 31 128 56 69 80 • Population growth (annual %), 2016 0.5 1.5 1.3 1.6 0.3 1.6 • Poverty headcount ratio, $1.90 a day (2011 PPP) (% of population) 1.9 (2013) .. 3 (2014) .. 0 (2013) 0.3 (2013) • Urban population (% of total), 2016 57 75 80 65 52 74 Health expenditure • Health expenditure per capita (current US$), 2014 420 456 677 570 228 568 • Health expenditure, total (% of GDP), 2014 5.5 4.2 6.3 8.8 4.1 5.4 • Health expenditure, public (% of total health expenditure), 2014 55.8 55.2 51.8 48.2 77.8 77.4 • Health expenditure, public (% of government expenditure), 2014 10.4 6.4 11.6 14.2 13.3 10.5 • Out-of-pocket health expenditure (% of total expenditure on health), 2014 32.0 35.3 44.0 6.5 11.9 17.8 Health • Life expectancy at birth, total (years), 2015 76 75 77 57 75 75 • Fertility rate, total (births per woman), 2015 1.6 1.9 2.2 2.5 1.5 2.1 • Mortality rate, under-5 (per 1,000 live births), 2015 11 7 13 41 12 14 • Births attended by skilled health staff (% of total) 100 (2013) 99 (2013) 96 (2012) .. 100 (2012) 97 (2013) • Immunization, DPT (% of children ages 12-23 months), 2016 99 98 97 66 99 98 • Prevalence of HIV, total (% of population ages 15-49), 2015 .. 0.4 0.2 19.2 1.1 .. • Improved water source (% of population with access), 2015 96 98 96 93 98 100 • Improved sanitation facilities (% of population with access), 2015 77 96 85 66 93 95 Education • Literacy rate, adult total (% of people ages 15 and above), 2015 96 95 95 95 94 96 • School enrolment, primary (% gross) 104.1 (2015) 101.8 (2015) 103.4 (2014) 99.7 (2014) 102.7 (2015) 102.5 (2015) • Primary completion rate, total (% of relevant age group) 92 (2015) 101 (2015) 105 (2014) .. 93 (2015) 92 (2015) • School enrolment, secondary (% gross) 94 (2015) 78 (2015) 91 (2014) 99 (2014) 129 (2015) 102 (2015) Source: World Development Indicators database (retrieved August, 2017) 2 Table 2 Thailand mortality and disease statistics, 1990-2015 Key indicators 1990 1995 2000 2005 2010 2015 Life expectancy at birth, (years) 67.2 74.8 69.2 76.2 70.5 77.3 Mortality rate, adult, male (per 1,000 male adults) 228 254 258 234 216 205 Mortality rate, adult, female (per 1,000 female adults) 136 135 137 124 111 104 Cause of death, by communicable diseases and maternal, prenatal and nutrition conditions (% of total) .. .. 26.1 24.3 20.7 18.3 Cause of death, by non-communicable diseases (% of total) .. .. 64.0 64.6 67.7 71.3 Cause of death, by injury (% of total) .. .. 9.9 11.0 11.6 10.4 Mortality caused by road traffic injury (per 100,000 people) .. .. 26.5 29.8 32.7 31.7 Prevalence of HIV, total (% of population ages 15-49) 0.5 1.9 1.7 1.4 1.3 1.1 Source: World Development Indicators database (retrieved August, 2017) 3 Table 3 Characteristics of the three public health insurance schemes in Thailand, 2017 Civil Servant Medical Benefit Scheme Social Health Insurance Universal Coverage Scheme Legislation Royal Decree 1980 Social Security Act 1990 National Health Security Act 2002 Purchaser Comptroller General Department, Ministry of Finance Social Security Office, Ministry of Labour National Health Security Office Population coverage, million 4.4 10.6 48 Source of finance Tax based, non-contributory Tripartite contribution by employer, employee and government Tax based, non-contributory Budgeting Open ended budget Closed ended budget Closed ended budget Expenditure, 2016, Thai Baht 71.02 billion 37.7 billion 109.3 billion Payment method OP: Fee-for-service, IP: DRG with multiple cost bands OP: Capitation, IP: DRG within global budget OP and prevention and health promotion: Capitation, IP: DRG with global budget; fee schedule for specific high cost procedures Source: Thai National Health Accounts 2013, International Health Policy Program, MOPH Note: OP = Out-patient, IP = In-patient, PP = health promotion and prevention 4 Table 4 Chronology of UCS benefit package extension Year Benefit package 2002 • Outpatient and Inpatient services, high cost care, accident and emergency, personal prevention and health promotion services, rehabilitation services, pre-hospital care 2006 • Universal Anti Retroviral Therapy including provision of medicines, voluntary counselling and testing, monitoring CD4 count, viral load testing and condoms distribution 2008-2009 • Thai Traditional Medicine • Renal replacement therapy: Peritoneal Dialysis First policy, haemodialysis, kidney transplants inclusive of all related medicines • Voluntary methadone replacement therapy for drug addictions • Access to expensive medicines in the national list of essential medicines, e.g. linezolid for methicillin resistant staphylococcus aurius, Botulinum A toxin for idiopathic cervical dystonia • Seasonal Influenza vaccination in at-risk groups 2010 • Access to all orphan medicines and antidotes • Treatment of psychiatric patients as inpatient without length of stay limits. 2011 • Secondary prevention for diabetes and hypertension • Specific medicines for psychiatric patients 2012 • Liver transplantation for hepatic failure in patients <18 years • Heart transplantation 2013 • Extension of seasonal influenza vaccine to more target groups • Stem cell transplantation in leukaemia and lymphoma with specific indications 2014 • Special earmarked budget for hard-to-reach areas 2015 2016 • Detect and treat policy for HIV, with any level of CD4 count • Long term home and community care for frail elderly • Home and community based psychiatric care 5 Table 5 Cost savings from central negotiation by NHSO for medical supplies and medicines, various years, US $ Market price per unit US$ Negotiated price per unit US$ Units purchased Cost difference US$ Cost savings US$ Medical supplies • Folding lens (2011-2012) 133 93 64,100 40 2,564,000 • Unfolding lens (2011-2012) 133 23 7,197 110 791,670 • Balloon stent (2009-2012) 667 23 26,655 334 8,902,770 • Coronary stent (2009-2012) 1,000 167 10,575 833 8,808,975 • Drug-coated stent (2009-2012) 2,833 567 33,794 2,266 76,577,204 • Drug eluting alloy stent (2012) 1,833 833 343 1,000 343,000 Medicines • ARV (2010-2012) 747 658 29,973 89 2,667,597 • High cost drug (2010-2012) 4,508 3,197 4,674 1,311 6,127,614 • Influenza vaccine (2010-2012) 7 5 643,319 2 1,286,638 • Erythropoietin (2009-2012) 22 8 1,634,239 14 22,879,346 • Continuous ambulatory peritoneal dialysis solution (2010-2012) 7 4 19,095,657 3 57,286,971 Total cost saving to UCS 188,235,785 Source: NHSO 2012

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